Healthcare Provider Details

I. General information

NPI: 1790704401
Provider Name (Legal Business Name): MARK ROBERT HEITZMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 FISHER RD MOB-A SUITE 2-1
BERLIN VT
05602-9516
US

IV. Provider business mailing address

PO BOX 547 CENTRAL VERMONT MEDICAL CENTER-FINANCE DEPT
BARRE VT
05641-0547
US

V. Phone/Fax

Practice location:
  • Phone: 802-225-5660
  • Fax: 802-229-2533
Mailing address:
  • Phone: 802-225-5660
  • Fax: 802-229-9533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number042.0006618
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number420006618
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: